The Role of Alcohol and Substance Use in Risky Sexual Behavior Among Older Men Who Have Sex With Men: A Review and Critique of the Current Literature

HIV incidence is increasing among men who have sex with men (MSM) despite years of prevention education and intervention efforts. Whereas there has been considerable progress made in identifying risk factors among younger MSM, older MSM have been largely neglected. In particular, the role of alcohol and drug use in conjunction with sex has not been thoroughly studied in older MSM samples. This article reviews the small body of literature examining the association of substance abuse and risky sexual behavior in this population and provides a methodological critique of the reviewed studies. The data show that older MSM are engaging in risky sexual behavior, with the likelihood of engaging in risky sexual activities increasing with the use of alcohol and other drugs. Methodological limitations prevent strong conclusions regarding whether the sexual risk behaviors of older MSM differ from those of younger MSM, and the extent to which alcohol and drug use may differentially contribute to engagement in sexual risk-taking as a function of age. Future research is needed to clarify these associations.     

Sensation Seeking Moderates the Effects of Alcohol and Drug Use Prior to Sex on Sexual Risk in Young Men Who Have Sex with Men

Men who have sex with men (MSM) account for more than half of all new HIV/AIDS diagnoses in the United States each year, and young MSM (ages 13–24) have the highest increases in new infections. Identifying which young MSM engage in sexual risk-taking in which contexts is critical in developing effective behavioral intervention strategies for this population. While studies have consistently found positive associations between the use of certain drugs and sexual risk, research on alcohol use as a predictor of risk has been less consistent. Participants included 114 young MSM from a longitudinal study of LGBT youth (ages 16–20 at baseline). Participants reported number of unprotected sex acts with up to nine partners across three waves of data collection spanning a reporting window of 18 months, for a total of 406 sexual partners. Sensation seeking was evaluated as a moderator of the effects of both alcohol and drug use prior to sex on sexual risk. Higher levels of sensation seeking were found to significantly increase the positive associations between frequency of unprotected sex and frequency of both alcohol use and drug use with partners. Follow-up analysis found that average rates of alcohol use moderated the association between alcohol use prior to sex and sexual risk, such that decreases in average alcohol use increased the positive association between these variables. Results suggest that while drug use with partners increased sexual risk for all young MSM, the effects of alcohol use prior to sex were limited in low sensation-seeking young MSM as well as those who are high alcohol consumers on average. Implications for future research and behavioral interventions are discussed.     

Predictors of Unrecognized HIV Infection Among Poor and Ethnic Men Who Have Sex with Men in Los Angeles

This study evaluates associations between unrecognized HIV infection and demographic factors, internalized homonegativity, drug use, and sexual behaviors among HIV positive men who have sex with men (MSM). We analyzed data from 347 HIV positive participants from the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV-Cooperative Agreement Program. Participants were HIV positive MSM and MSM/W and predominantly African American (36.0%) or Latino (38.7%), and unemployed (82.8%). Results from a multivariate logistic regression suggest that, compared to HIV positive participants who correctly reported their HIV positive status, being African-American (OR: 9.81, CI: 1.2–77.9) or Latino (OR: 10.92, CI: 1.3–88.4) rather than White, MSM/W rather than MSM (OR: 3.24, CI: 1.09–9.62), and having higher homonegativity scores (OR: 1.22, CI: 1.02–1.4) is associated with unrecognized HIV infection, controlling for age, education, and homelessness. Findings provide some immediate evidence to help craft HIV prevention interventions.     

An Integrated Theoretical Approach to Substance Use and Risky Sexual Behavior Among Men Who Have Sex with Men

Research demonstrates a consistent association between substance use and sexual risk, particularly among men who have sex with men (MSM). The present study builds upon two existing theories (Cognitive Escape Theory and Expectancy Theory) to examine the synergistic role of sexual conflict (surrounding unsafe sex) and expectancies in sexual behavior among 135 MSM. Two conflicts were examined: (1) The conflict between motivation to practice safer sex and temptation for unprotected sex; and (2) The conflict between motivation to practice safer sex and perceived benefits of unprotected sex. Factorial ANOVAs (2 × 2; high versus low expectancies and conflict versus no conflict) revealed a significant interaction between conflict and expectancies—individuals who reported high levels of conflict were more sensitive to the effect of expectancies than were those experiencing low levels of sexual conflict. Results demonstrate the synergistic effects of conflict and expectancies and highlight the importance of integrating existing theories to more fully consider the intrapsychic operation and experience of sexual conflicts.     

Moderating Effects of Age on the Alcohol and Sexual Risk Taking Association: An Online Daily Diary Study of Men Who have Sex with Men

Men who have sex with men (MSM) account for the majority of HIV/AIDS diagnoses and data suggest infection rates are rising. Identification of factors that increase the risk of infection is key to the development of effective prevention programs. Previous research has been inconsistent regarding the link between alcohol consumption and sexual risk taking among MSM. Daily reports of alcohol consumption and sexual behavior were completed for up to 30 days by 143 HIV negative MSM recruited online. This resulted in 2,887 daily reports of number of sex partners and 549 episodes of sex. Independent variables included age, number of standard drinks consumed, and partner type. Outcome variables included sex with a partner, a composite sexual risk variable, and unprotected anal intercourse (UAI). Alcohol consumption significantly increased the odds of having sex and had a significant positive association with the sexual risk composite variable. Age was a significant moderator of the association between alcohol consumption and sexual risk taking, with the effects of alcohol increasing with age. For example, at the 75%tile of age (37 years old), the odds of UAI increase from ∼0.2 to 0.35 as the number of alcoholic drinks increases from zero to seven. Partner type did not have significant effects. Daily reports of alcohol consumption had a significant within-person association with sexual risk behaviors, particularly among older MSM. Findings highlight the importance of measuring individual differences as moderators of the association between alcohol and risky sexual behavior.     

Depression is Associated with Sexual Risk Among Men Who Have Sex with Men,but is Mediated by Cognitive Escape and Self-Efficacy

Men who have sex with men (MSM) show high rates of HIV infection, and higher rates of depression than non-MSM. We examined the association between depression and sexual risk among “high risk” MSM. Evidence has been mixed regarding the link between depression and risky sex, although researchers have rarely considered the role of psychosocial vulnerabilities such as self-efficacy for sexual safety or “escape” coping styles. In a national sample (N = 1,540) of HIV-positive and HIV-negative MSM who reported unprotected sex and drug use with sex partners, we found evidence that depression is related to HIV transmission risk. Self-efficacy for sexual safety and cognitive escape mediated the link between depression and risk behavior, suggesting that psychosocial vulnerability plays an important role in the association of depression with sexual risk. These findings may help us construct more accurate theories regarding depression and sexual behavior, and may inform the design of sexual safety interventions.     

Intertwining Epidemics: A Review of Research on Substance Use Among Men Who Have Sex with Men and Its Connection to the AIDS Epidemic

This paper reviews the (1) literature on substance use among men who have sex with men (MSM), (2) data that test whether connections between substance use and abuse and high-risk sexual behavior exist among MSM, and (3) ways that HIV interventions might address the effects of substance use on high-risk sexual behavior. We conclude that while alcohol use patterns are not substantially different between gay and heterosexual men, gay men do use more kinds of other drugs. Although there is considerable evidence to support the view that substance use patterns have declined among gay men since the mid-1980s, substance use should still be regarded as a health risk in this population. Although the associations between substance use and sexual risk-taking for HIV are complex, the inclusion of interventions to disentangle substance use and high-risk sexual practices may increase the efficacy of AIDS prevention efforts among gay men.     

Trauma symptoms,internalized stigma,social support,and sexual risk behavior among HIV-positive gay and bisexual MSM who have sought sex partners online

Gay, bisexual, and other men who have sex with men (MSM) remain the highest risk group for HIV infection. One reason is the increased use of the Internet to meet potential sex partners, which is associated with greater sexual risk behavior. To date, few studies have investigated psychosocial predictors of sexual risk behavior among gay and bisexual men seeking sex partners online. The purpose of the current study was to test a conceptual model of the relationships between trauma symptoms indexed on the event of HIV diagnosis, internalized HIV stigma, and social support on sexual risk behavior among gay and bisexual MSM who seek sex partners online. A sample of 142 gay and bisexual MSM recruited on- and offline completed a comprehensive online assessment battery assessing the factors noted above. A number of associations emerged; most notably internalized HIV stigma mediated the relationship between trauma-related symptoms indexed on the event of HIV diagnosis and sexual risk behavior with HIV-negative and unknown serostatus sex partners. This suggests that gay and bisexual MSM who are in greater distress over their HIV diagnosis and who are more sensitive to HIV stigma engage in more HIV transmission risk behavior. As sexual risk environments expand with the increasing use of the Internet to connect with others for sex, it is important to understand the predictors of sexual risk behavior so that tailored interventions can promote sexual health for gay and bisexual MSM seeking sex online.     

Feasibility and Promise of a Couple-Based HIV/STI Preventive Intervention for Methamphetamine-Using,Black Men Who have Sex with Men

Accumulating evidence supports couple-based approaches for HIV/STI preventive interventions. Yet, to date, no studies have examined couple-based sexual risk reductions intervention specifically for men who have sex with men (MSM) from populations with elevated rates of HIV/STI transmission, such as black MSM and methamphetamine-involved MSM. We pilot tested—using a pre-/post-test design—a seven-session couple-based intervention for black, methamphetamine-using, black MSM couples engaging in sexual risk. Feasibility was assessed via recruitment and retention rates; potential efficacy relied on self-reported sexual risk and drug use prior to and two months following intervention delivery. We enrolled 34 couples (N = 68 men). Over 80% attended all seven intervention sessions, and retention exceeded 95% at two-month follow-up. At follow-up, participants reported significantly fewer sexual partners, fewer episodes of unprotected anal sex, and greater condom use with their main partner; participants also reported significantly less methamphetamine use, any illicit drug use, and number of illicit drugs used. These findings indicate that couple-based HIV/STI intervention is feasible and promising for at-risk black MSM couples.     

Results from Two Online Surveys Comparing Sexual Risk Behaviors in Hispanic,Black, and White Men Who Have Sex with Men

Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.     

Substance Use During Sex and Sensation Seeking as Predictors of Sexual Risk Behavior Among HIV+ and HIV− Gay Men

Substance use (i.e., use of recreational drugs and alcohol) has been associated with HIV-related sexual risk behavior in several studies involving gay men. One explanatory hypothesis proposes that substance use and sexual risk behavior are both a function of underlying personality traits. This paper examines sensation seeking and alcohol and drug use during sex as predictors of unprotected anal and oral sex and of a sexual risk index. The sample includes 117 predominantly gay-identified men (73 HIV+ and 44 HIV–) who participated in a 5-year natural history study of HIV disease in New York City. Repeated measures regression analyses tested predictor variables individually and in models including all predictor variables simultaneously. Alcohol use, drug use, and sensation seeking were each significantly associated with all sexual risk behavior variables when entered individually. When predictor variables were entered simultaneously in analyses involving unprotected receptive and insertive anal sex, sensation seeking remained a significant predictor, with substance use typically falling to marginal significance. However, significant associations between substance use and the other sexual risk behavior variables (oral sex and a risk index) are maintained even when controlling for sensation seeking. The results suggest that sensation seeking may partially account for the association between substance use and sexual risk behavior, but substantial independent associations also exist.     

Negative Affect and Unsafe Sex in HIV-Positive Men

This cross-sectional study of 155 sexually active HIV-positive men (48% homosexual, 39% bisexual, 13% heterosexual) sampled at an outpatient clinic in Los Angeles found that negative affective states (depression-dejection, tension-anxiety, confusion-bewilderment, anger arousal, and keeping anger inward) were significantly associated with having engaged in unprotected anal intercourse in the most recent sexual encounter with a male partner. Negative affect was not associated with unprotected vaginal or anal intercourse with most recent female partners. Path analyses suggested that the association of negative affect (composite score) and unsafe sex with male partners was mediated by participants' use of alcohol/drugs in the 3 hours before the sexual encounter. Additionally, the association of depression-dejection and unsafe sex tended to be mediated by attributions of responsibility for protecting sex partners (i.e., more responsibility attributed to partners than to self). The findings support a psychological escape model of sexual risk behavior in seropositive men and demonstrate the need for secondary prevention programs for HIV-positive persons.     

Sexual Risk Profile of Young Men in Vancouver, British Columbia, Who Have Sex with Men and Inject Drugs

We compared sexual risk behaviors of men who have sex with men and inject drugs (MSM/IDU) with those of other men who have sex with men (MSM). Of 910 MSM surveyed, 106 (12%) injected drugs in the previous year. MSM/IDU were younger than MSM and more likely to be HIV-seropositive, Aboriginal, economically disadvantaged, engaged in the trade of sex for money or drugs, and to report having female sexual partners. MSM/IDU reported more casual sexual partners and in multivariate analyses were twice as likely to report unprotected receptive anal intercourse with casual partners. These results, combined with those from previous analyses, suggest that the higher risk for HIV seroconversion among MSM/IDU in this cohort is attributable mainly to sexual rather than injection-related exposures. Controlled assessments are needed to identify optimal sexual risk reduction strategies for MSM/IDU.     

Associations Between Drug and Alcohol Use Patterns and Sexual Risk in a Sample of African American Men Who Have Sex with Men

Men who have sex with men (MSM) are the largest risk group in the US HIV epidemic and African American MSM (AA MSM) are disproportionately affected. Substance-abusing sexual minorities warrant attention as they are at elevated risk for HIV, yet are not a homogeneous risk group. The purpose of this study was to use latent class analysis to identify patterns of drug and alcohol use in a sample of 359 AA MSM and examine associations with sexual risk. Three classes were identified: Individuals who used multiple substances (poly-users) (18 %), alcohol/marijuana users (33 %) and individuals who had low probability of reporting drug or problematic alcohol use (50 %). Results from multivariate analysis indicate that poly-users were older and more likely to report sex exchange and recent sexually transmitted infection compared to the other classes. Alcohol and poly-users were more likely to report sex under the influence. Identifying and defining substance use patterns can improve specification of risk groups and allocation of prevention resources.     

Alcohol Use and Associated Sexual and Substance Use Behaviors Among Men Who Have Sex with Men in Moscow,Russia

Alcohol use is a public health problem in the Russian Federation. This study explored relationships between alcohol use and behavioral risks for HIV transmission among men who have sex with men (MSM) in Moscow, Russia. Alcohol use disorder identification test (AUDIT) scores for 1367 MSM participating in a cross-sectional survey and HIV testing were categorized to: “abstinence/low use”, “hazardous use”, “harmful use/dependency”. Multiple logistic regression models compared dependent variables for sexual and drug use behaviors across alcohol use strata. Hazardous and harmful/dependent alcohol use were significantly associated with high-risk sexual behaviors and drug use. Harmful use/dependency was associated with an increased odds of having more than five male sex partners (last 12 months; adjusted odds ratios—AOR 1.69; 95 % CI 1.25–2.27), inconsistent condom use during anal intercourse (AOR 2.19; 95 % CI 1.61–2.96) and, among those using recreational drugs, injection drug use (last month; AOR 4.38: 95 % CI 1.13–17.07) compared to abstinent/low-level users. Harmful/dependent use was marginally associated with HIV infection (AOR 1.48; 95 % CI 0.97–2.25). HIV prevention efforts for MSM in Moscow may benefit from addressing problem alcohol use to mitigate high-risk behaviors.     

Recreational Viagra Use and Sexual Risk among Drug Abusing Men

Until recently, the Viagra connection to HIV was anchored in older adults. However, CDC investigation showed stability in 50+ HIV diagnoses on the heels of upward trends in risk indicators among men who have sex with men (MSM) and substance abusing populations. Signs have increasingly pointed to recreational drug use among younger populations, to which Viagra is being added to the mix. Currently, the field is still locating the substance abuse, sexual risk and age-related dimensions of Viagra misuse. Recent studies identify it primarily as substance abuse, but the majority reports a combination of risky sex and risky drug use. At the very least, Viagra appears related to the enhancement of sexual experience or performance, even when it is used to compensate for erectile dysfunction caused by other drugs-either illicit or prescribed (e.g., antidepressants and highly active antiretroviral therapy or HAART). The populations studied, however, frequently have limited the generalizability of findings. This report analyzes the relationship among Viagra, Club Drugs and HIV sexual risk behavior in drug using men with a sample diverse in sexual orientation and demographic scope. Participants were 640 males recruited from three HIV prevention programs in Los Angeles County. Mean age was 43.97 years, ranging from 18.7 to 70.3 with almost 25% over 50. Sexual orientation was 79% heterosexual, 8% bisexual and 12% gay. Racial composition was 45% white, 35% black and 19% Hispanic. NIDA's Risk Behavior Assessment and a Club Drug/Viagra addendum were used to collect socio-demographic, substance use and sexual risk data. Multiple logistic regression models were constructed along with chi-square tests of association and some t-tests. White race was a major risk factor. No age effect was found. MSM were more likely to use Viagra. Insertive anal sex was a significant co-factor among heterosexual Viagra users involved in transactional sex with women. In the overall sample and the subsets of heterosexual, MSM, younger and older men, predictive models all identified club or designer drugs as significant co-factors in the use of Viagra. Different patterns of drug co-factors were observed for each subset. We detected consistent positive associations between the use of Viagra and the use of amphetamines immediately before or during sex. Viagra use has moved into a new generational context and now complicates the sexual risk and intervention equations for all men, particularly MSM as well as more hidden subgroups.     

Alcohol Use and Risk of HIV infection among Men Who Have Sex with Men

In the United States, men who have sex with men (MSM) currently represent more than 50% of those living with HIV and over 70% of HIV+ men (CDC 2007, ). Male-to-male sexual contact has been identified as the predominant route of transmission among this sub-group, which underscores the need for research that targets risk factors associated with risky sex-related HIV acquisition. Along these lines, research has shown that one potentially important predictor variable for risky sex among MSM is alcohol use. The major aim of this paper is to review and integrate empirical evidence on the association of alcohol use and risky sex among MSM. A summary of the quantitative research is provided first, followed by a critique of the reviewed literature, a discussion of the consistency of the existing empirical evidence with predictions of current theories, and finally, recommendations for future research designed to evaluate alcohol-related sexual risk in MSM.     

Developmental Change in the Relationship Between Alcohol and Drug Use Before Sex and Sexual Risk Behavior in Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) are the only group in which rates of new HIV infections are increasing in the United States. Alcohol and drug use have been linked to HIV risk, but evidence suggests that these associations may change across development and by relationship type. Data were taken from an analytic sample of 114 YMSM enrolled in a longitudinal study of lesbian, gay, bisexual and transgender youth with 4 years of participant follow-up. For the sample as a whole, alcohol use before sex was not associated with sexual risk, but drug use before sex was positively associated with sexual risk. A positive association between alcohol use and sexual risk emerged across development, and this association was stronger in serious relationships relative to casual sex partners. The positive association between drug use before sex and sexual risk decreased across development and was stronger in serious relationships. We discuss the need for addressing substance use before sex in dyadic interventions with YMSM.     

Being high and taking sexual risks: findings from a multisite survey of urban young men who have sex with men.

Adolescent and young adult males who have sex with men (MSM) remain at high risk of HIV infection. Many sexual risk factors have been identified, yet the role of substance use remains controversial. We assess the extent to which urban young MSM report being "high" on drugs or alcohol during sex and the association between being "high" and unprotected anal intercourse (UAI). During summer 2000, 3,075 MSM aged 15-25 years completed a 20-minute interview for the Community Intervention Trial for Youth Project. Participants were asked about their last sexual contact with main and nonmain partners, including whether they were "high on drugs or alcohol." 18.6% of MSM with a main partner reported being high during their last sexual encounter; 25.0% reported UAI. Among men with a nonmain partner, 29.3% reported being high, and 12.3% reported UAI. Being high was associated with unprotected receptive anal intercourse with nonmain partners (odds ratio = 1.66, p = .02). HIV prevention should include messages about the potential dangers of drinking and drug use in situations where sexual encounters with nonmain partners may occur.     

A Review of the Literature on Event-Level Substance Use and Sexual Risk Behavior Among Men Who Have Sex with Men

In the United States, there continues to be high incidence of HIV infection among men who have sex with men (MSM), who represent 57% of new infections in 2009. While many studies report associations between non-injection substance use and sexual risk behavior among MSM, overall results are mixed. Summarizing these studies is difficult because researchers have used a variety of assessment periods for substance use and sexual behavior. We review the scientific literature on event-level measures, which assess substance use and sexual risk behavior immediately before or during a sexual encounter and provide the most precise link between these two behaviors. From January 2009 through March 2010, we searched four databases: Ovid (MEDLINE and PsycINFO), Web of Knowledge, and Sociofile. Across studies, results varied by substance with little within substance consistency or a lack of research except for two notable exceptions: methamphetamine and binge alcohol use. The findings underscore the importance of providing HIV risk-reduction interventions for substance-using MSM.